THE PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 (PDM-2): Assessing Patients for Improved Clinical Practice and Research

Vittorio Lingiardi, MD Nancy McWilliams, PhD Sapienza University of Rome Rutgers University Robert F. Bornstein, PhD Francesco Gazzillo, PhD Adelphi University Sapienza University of Rome Robert M. Gordon, PhD Allentown, Pennsylvania

This article reviews the development of the second edition of the Psychodynamic Diagnostic Manual, the PDM-2. We begin by placing the PDM in historical context, describing the structure and goals of the ﬁrst edition of the manual, and reviewing some initial responses to the PDM within the professional community. We then outline 5 guiding principles intended to maximize the clinical utility and heuristic value of PDM-2, and we delineate strategies for implementing these principles throughout the revision process. Following a discussion of 2 PDM- derived clinical tools—the Psychodiagnostic Chart and Psychodynamic Diagnostic Prototypes, we review initial research ﬁndings documenting the reliability, validity, and clinical value of these 2 measures. Finally, we discuss changes proposed for implementation in PDM-2 and the potential for an updated version of the manual to enhance clinical practice and research during the coming years. Keywords: PDM, DSM, diagnosis, personality, PDM-2-derived clinical tools

The ﬁrst edition of the Psychodynamic Diagnostic Manual (PDM Task Force, 2006) was This document is copyrighted by the American Psychological Association or one of its allied publishers. published during a critical era of change in mental nosology. This period began in 1980 This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. with the publication of the Diagnostic and Statistical Manual of Mental Disorders

Vittorio Lingiardi, MD, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome; Nancy McWilliams, PhD, Graduate School of Applied and Professional Psychology, Rutgers University; Robert F. Bornstein, PhD, Derner Institute of Advanced Psychological Studies, Adelphi University; Francesco Gazzillo, PhD, Department of Dynamic and Clinical Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome; Robert M. Gordon, PhD, Independent Practice, Allentown, Pennsylvania. Correspondence concerning this article should be addressed to Vittorio Lingiardi, MD, Sapienza University of Rome, Via dei Marsi, 78-00185 Rome, Italy. E-mail: [email protected]

94 PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 95 (DSM)ÐIII, which represented a shift from a psychoanalytically influenced, dimensional, inferential diagnostic system to a “neo-Kraepelinian” descriptive, multiaxial classification that relied on present-versus-absent criteria sets for identifying discrete mental disorders. This paradigm shift was adopted deliberately, with the aim of removing the psychoanalytic bias from the manual now that other theoretical orientations were common, including cognitiveÐbehavioral, family systems, humanistic, and biological. The shift was also intended to make certain kinds of outcome research easier: Present-versus-absent traits could be identified by researchers with little clinical experience, whereas the previous classifications (DSM-I and DSM–II) had required significant clinical training to diagnose inferentially many of the syndromes described. Each succeeding edition of the DSM has included more discrete disorders (see Clegg, 2012). The publication of DSM–IV (Amer- ican Psychiatric Association, 1994) continued the neo-Kraepelinian descriptive trend, which has been further elaborated and expanded with the recently published DSM-5 (APA, 2013). Although the DSM is considered by many as a permanent fixture in the world of mental health—a set of guidelines and diagnostic criteria that, for better or worse, will always guide our clinical work—this belief is based more on history and habit than anything else. The DSM-I (American Psychiatric Association, 1952) was published just over 60 years ago. The manual is not a government document (although the development of DSM-I was in part a government effort), nor is it in any way related to policies and procedures endorsed by the National Institute of Mental Health (see Insel, 2013). The DSM is not the most widely used diagnostic system today: The International Classification of Diseases (ICD-10; World Health Organization, 2004) takes that prize. Despite its aura of inevitability, the current version of the diagnostic manual, the DSM-5 (American Psychiatric Association, 2013), is a privately published book, a product of the American Psychiatric Association, intended to guide the professional activities of mental health professionals, but also to shape the reimbursement policies of managed care organizations and to fund various activities of the association. Although early editions of the manual were applauded for systematizing what had been, prior to World War II, a somewhat chaotic array of overlapping diagnostic systems emerging from different theoretical traditions, more recent editions of the DSM have been increasingly controversial (see, e.g., Cooper, 2004; Vanheule, 2012). Beginning in Octo- ber of 2014, the Health Insurance Portability and Accountability Act (HIPPA) has required clinicians to provide ICD-10—not DSM-5—codes for reimbursement. More- over, although advances in biological and cognitive research have tended to dominate recent discussions of diagnosis, assessment, and treatment, psychoanalytic concepts have undergone a quiet resurgence as well, not only in clinical psychology, but in myriad other

This document is copyrighted by the American Psychological Association or one of its allied publishers. subﬁelds (e.g., cognitive, social, developmental, neuropsychological; see Protopopescu &

This article is intended solely for the personal use of the individual user and is not to be disseminatedGerber, broadly. 2013; Wilson, 2009). Recent critiques of the DSM have touched upon its problematic political and economic aspects, but they have not ended there. Clinicians and clinical researchers have also questioned the DSM emphasis on a disease model of psychopathology, which works better for some syndromes (e.g., schizophrenia) than others (e.g., narcissistic personality disorder). Critics have noted the expansion in the number of categories in DSM-5 (Batstra & Frances, 2012; Frances, 2013), and have questioned the Kraepelinian nature of DSM diagnoses, with their continued adherence to categorical classification, even for those disorders which may be best conceptualized as reflecting continua of functioning, with no sharp cutoff between normality and pathology (see Craddock & Owen, 2010; Livesley, 2010). Beyond questions regarding the overarching framework of DSM-5 (Good, 2012; 96 LINGIARDI ET AL. Zimmerman, 2012), and its choice of syndrome and symptom descriptors (Huprich, 2011), much of the current opposition to DSM-5 may be seen as a product of the process used to create it (Bornstein, 2011). Any classification system that is based on the work of a committee (or set of committees) will never be completely free of politics and personal preference. Nonethe- less, as a number of writers have pointed out—including some who were involved in earlier DSM revisions (e.g., Frances, 2011; Livesley, 2010; Widiger, 2011)—the DSM-5 revision process differed from earlier efforts in ways that have concerned many researchers and practitioners. First, the process of developing DSM-5 lacked the transparency on which good science depends. Even though progress toward DSM-5 was periodically updated online, giving the public some chances to submit comments and observations, it is arguable that the priceless opportunity to have a real open dialogue with the clinical and scientific communities was partially lost. Members of the DSM-5 work groups were asked not to reveal details of their deliberations to other mental health professionals, the media, or members of the public, presumably in an effort to avoid being unduly influenced by those who might have a vested interest in the outcome of work group decisions. Although such a strategy has the advantage of minimizing the potential biasing effects of outside forces (e.g., representatives from managed care organizations and pharmaceutical com- panies), it may foster groupthink, increasing the possibility that decisions will be driven by interpersonal dynamics within work groups (e.g., the persuasive power of individual committee members; see Turner & Pratkanis, 1998). In the absence of a real conversation with the whole community, faux pas such as the proposed deletion of the narcissistic personality disorder were perhaps inevitable (about the controversy over the proposed elimination of some personality disorders in the DSM-5, see Shedler et al., 2010). Second, as several critics (e.g., Bornstein, 2011; Ronningstam, 2011; Widiger, 2011) noted, the reviews of relevant literature by DSM-5 work groups was selective: Large areas of empirical evidence were not considered. The work groups failed to give detailed rationales for their decisions about what to include and what to exclude. Finally, the DSM-5 is mainly based on self-report data. A plethora of evidence from cognitive and social research confirms that people are, at best, flawed perceivers of their traits, behaviors, and internal states; our inherent introspective limitations are magnified when psychological symptoms (e.g., anxiety, personality pathology, situational variations in mood) are present (Huprich, Bornstein & Schmitt, 2011). Although, when used in combination with self-report instruments, performance-based measures have proven useful in illuminating underlying dynamics and in documenting meaningful divergences between patients’ inner experience and the outward expression of that experience (see Bornstein, 2010; Ganellen, 2007), studies involving multimethod assessment strategies This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminatedplayed broadly. virtually no role in the DSM-5 revision process. For all these reasons, we think that the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006) adds a needed perspective to the DSM-5 and other mainly categorical diagnostic systems. In addition to considering symptom patterns described in existing taxonomies, it enables clinicians to describe and categorize personality patterns, related social and emotional capacities, unique mental proﬁles, and personal experiences of symptoms. It provides a framework for improving comprehensive treatment approaches and for understanding the biological and psychological origins of both mental health and mental illness. In focusing on the full range of mental functioning, the PDM complements the DSM and ICD efforts to catalogue symptoms and syndromes. In contrast to the DSM, the PDM has aspired to be a taxonomy of people rather than diseases, and has concep- PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 97 tualized its main purpose as helping clinicians to diagnose complex psychopathologies, formulate individual cases, and plan the best possible treatment for each patient. The following statement by the American Psychoanalytic Association appeared on www.apsa.org in October 2013:

The DSM-5, published by our colleague organization the American Psychiatric Association, has been met with both praise and criticism. Like its predecessors, this fifth edition of the Diagnostic and Statistical Manual will be widely used in the mental health field to classify mental disorders according to diagnoses based on descriptive criteria. There is a place in the field for classifying patients based on descriptions of symptoms, illness course, and other objective facts. However, as psychoanalysts, we know that each patient is unique. No two people with depression, bereavement, anxiety or any other mental illness or disorder will have the same potentials, needs for treatment or responses to efforts to help. Whether or not one finds great value in the descriptive diagnostic nomenclature exemplified by the DSM-5, psychoanalytic diagnostic assessment is an essential complementary assessment pathway which aims to provide an understanding of each person in depth as a unique and complex individual and should be part of a thorough assessment of every patient. Even for psychiatric disorders with a strong biological basis, psychological factors contribute to the onset, wors- ening, and expression of illness. Psychological factors also influence how every patient engages in treatment; the quality of the therapeutic alliance has been shown to be the strongest predictor of outcome for illness in all modalities. For information about a diagnostic framework that describes both the deeper and surface levels of symptom patterns, as well as of an individual’s personality, emotional and social functioning, mental health professionals are referred to the Psychodynamic Diagnostic Manual.

The value of the PDM as a complement to the DSM has been recognized by DSM-5, in its Pocket Guide to the DSM-5 Diagnostic Exam (Nussbaum, 2013):

ICD-10 is focused on public health, whereas the Psychodynamic Diagnostic Manual (PDM) focuses on the psychological health and distress of a particular person. Several psychoanalytical groups joined together to create PDM as a complement to the descriptive systems of DSM-5 and ICD-10. Like DSM-5, PDM includes dimensions that cut across diagnostic categories, along with a thorough account of personality patterns and disorders. PDM uses the DSM diagnostic categories but includes accounts of the internal experience of a person presenting for treatment. (pp. 243Ð244)

With these observations as context, a brief description of the PDM structure and “philosophy” follows. The PDM uses a multidimensional approach to describe the intricacies of each patient’s functioning and ways of engaging in the therapeutic process. In this way, it attempts to provide a comprehensive proﬁle of an individual’s mental life.

This document is copyrighted by the American Psychological Association or one of its allied publishers. The ﬁrst edition covered adults, children and adolescents, and infants, emphasizing

This article is intended solely for the personal use of the individual user and is not to be disseminatedindividual broadly. variations as well as commonalities. It included four major sections: Classifi- cation of Adult Mental Disorders, Classification of Child and Adolescent Mental Health Syndromes, Classification of Infant and Early Childhood Disorders, and Conceptual and Empirical Foundations for a Psychodynamically Based Classification System for Mental Health Disorders. Part 1—the adult section—opened with the Personality Patterns and Disorders (P) axis, followed by the Profile of Mental Functioning (M) axis. The patients’ symptoms (and syndromes and their subjective experience of them; S axis) was intended to capture the phenomenology of mental illness—the personal, private experience of suffering—from the perspective of the patient. These three subsections were followed by illustrative case formulations demonstrating this more holistic, biopsychosocial kind of diagnosis. Part 98 LINGIARDI ET AL. 2—the child and adolescent section—reordered things a bit, on the basis of respect for the developing nature of children’s psychologies, and opened with the Profile of Mental Functioning axis, followed by the Emerging Personality Patterns and Disorders axis, then the Subjective Experiences axis. A special Section on Infancy and Early Childhood Mental Health Disorders followed. Part 3 contained a selection of relevant empirical papers by noted scholars on psychodynamic diagnosis and psychotherapy research. Schematically, according to this structure, the clinician should assess the following in all patients (except infants, assessed with Infancy and Early Childhood): ● Level of personality organization and the prevalent personality styles or disorders (Axis P for adults and Emerging Personality Patterns and Disorders for adolescents and children). ● Level of overall mental functioning (Axis M for adults and Axis Profile of Mental Functioning for adolescents and children), on the basis of the evaluation of nine different but partly overlapping capacities ([a] capacity for regulation, attention, and learning; [b] capacity for relationships; [c] quality of internal experience and level of confidence and self-regard; [d] affective experience, expression, and communication; [e] defensive patterns and capacities; [f] capacity to form internal representations; [g] capacity for differentiation and integration; [h] self- observing capacity or psychological-mindedness; [i] capacity for internal standards and ideals), each assessed along a continuum with four possible levels. After having assessed the level of these capacities, the clinician has to assess on a continuum of eight possible levels the overall health/sickness of the mental functioning of the patient. ● Symptoms and syndromes and the patient’s subjective experience of them (Axis S for adult and Subjective Experiences for adolescents). PDM diagnoses are prototypic because this manual, unlike the DSM, is not based on the addition of symptoms within a category; that is, it is not based on polythetic diagnosis. The PDM considers each disorder as a constellation of signs, symptoms, or personality traits that constitute a unity of meaning. It attempts to capture the gestalt of human complexity while combining the precision of dimensional systems and the ease of categorical applications (Gazzillo, Lingiardi, & Del Corno, 2012).

The PDM’s Fortunes So Far

The ﬁrst edition of the PDM in the United States and in Europe met with considerable

This document is copyrighted by the American Psychological Association or one of its allied publishers. commercial success and has inﬂuenced many practitioners and researchers. The New York

This article is intended solely for the personal use of the individual user and is not to be disseminatedTimes broadly. reviewed the PDM on January 24, 2006, with the headline, “For Therapy, a New Guide With a Touch of Personality,” and in the United States, the manual has received an adequate welcome also in the clinical literature, as demonstrated by the 2011 monographic issue of the Journal of Personality Assessment titled, “Can the Psychodynamic Diagnostic Manual (PDM) Put the Complex Person Back at the Center-Stage of Personality Assess- ment?” Shortly after its publication, Nancy McWilliams (2008) wrote an article on the PDM for Psychiatric Times, outlining its background, explicating Greenspan’s approach to diagnosis, and describing each section, including the one on infancy (which has received the most positive reaction from the community of practitioners). Finally, she provided a clinical example intended to demonstrate how the PDM can capture the entire functioning PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 99 of a patient’s personality. In the monographic issue of the Journal of Personality Assessment, McWilliams (2011a) describes the PDM, whose explicit purpose is to help clinicians to become more therapeutically effective, as a worthy first effort to compensate for the limitations of descriptive psychiatric diagnosis. In Hansell and Damour’s (2008) book Abnormal Psychology, the PDM is also presented as “an alternate classification system” to the DSM, which clinicians can use instead of, or as a supplement to, its descriptive classification. Reviewing the PDM in the Journal of the American Psychoan- alytic Association, Peter Dunn (2008) states that the manual conforms with the basic framework of the DSM and its coding system, but adds essential content from the psychoanalytic and psychodynamic tradition. An interesting study by Robert Gordon (2008, 2009) examined how psychologists with different training and theoretical orientations (psychodynamic, cognitiveÐbehavioral, and other nonpsychodynamic preferences, respectively) judged the PDM. Results showed that the manual received a highly favorable evaluation by all psychologists, irrespective of theoretical orientation. Participants in the study emphasized the value of the PDM’s jargon-free language and commented on its usefulness in helping nonpsychodynamic clinicians to formulate a clinically relevant diagnosis. According to Paul Stepansky (2009), the PDM’s exposure in the United States has been quite extensive. “To achieve commercial success of this order, the ‘psychoanalytic’ appellation must be diluted to ‘psychodynamic,’ and the psychodynamic ‘terms’ and ‘concepts’ offered in a user-friendly format intended to broaden rather than supplant other diagnostic frameworks. This is the very formula that has made the recently self-published Psychodynamic Diagnostic Manual, collectively authored by an ‘Alliance of Psychoan- alytic Organizations,’ a stunning success, with sales, as of March 2008, of over 20,000 copies” (p. 66). Stepansky further notes that the PDM was not intended to replace existing diagnostic manuals, but to be integrated with them. The PDM has also aroused interest in other countries, as shown by the interview with Nancy McWilliams conducted by George Halasz (2008) and published in the journal Australasian Psychiatry. The emphasis in the interview is on how the manual can be usefully implemented for clinical purpose and teaching. In Europe, the PDM’s diffusion and reception have been investigated by Franco Del Corno and Vittorio Lingiardi (2012), who noted that (a) in the German professional literature, references to the manual are mostly linked to the PDM’s chapter on the operationalized psychodynamic diagnosis (OPD Task Force, 2001); (b) in Spanish and Portuguese-speaking countries (Ferrari, 2006; Ferrari, Lancelle, Pereira, Roussos, & Weinstein 2008), a group of psychoanalysts proposed a Reportes de investigation about the PDM and announced a Spanish version of the manual, while Rosenthal (2008)

This document is copyrighted by the American Psychological Association or one of its allied publishers. characterized the PDM as a way to reconcile the psychoanalytic therapies with scientiﬁc

This article is intended solely for the personal use of the individual user and is not to be disseminatedinquiry; broadly. (c) in Turkey, Dereboy (2013, personal communication) is striving to introduce the PDM to training programs for medical residents and graduate students; (d) in France, Widlocher (2007) wrote a very favorable review of the manual with the subtitle “From nosographic to psychopathologic,” in which he argued that the psychoanalytic tradition is the best context for the development of new and more complex classiﬁcations of psychiatric disorders that may be complementary to the DSM; more recently, Widlocher and Thurin (2011) cited the PDM as an effort to integrate a dynamic perspective about psychopathology with a symptom-behavior-oriented diagnosis; (e) in Italy, the PDM was translated and published in 2008. The clinical value of the manual is mentioned in many Italian papers, research projects, books, seminars, academic courses, and training programs. Appreciation of its utility is beginning to spread in clinical settings as well. 100 LINGIARDI ET AL. Despite these instances of international appreciation of the PDM, there are many areas—both in the United States, where it was originally published, and in other countries—where the manual is virtually unknown. We believe that this unevenness of visibility is a result of the decision that Stanley Greenspan initially made to self-publish the PDM, so that he could keep its price as low as possible, making it affordable especially to the students he hoped it would inﬂuence. To avoid the problem of uneven impact in the future, we have decided to contract from now on with an established publishing company, whose marketing practices will ensure far greater exposure for PDM-2 and any later versions of the manual. The new edition of the PDM will be published simultaneously in the United States by the Guilford Press and Italy by the publisher Raffaello Cortina, and publishers in other countries (in Europe and Asia) are already interested in translating the PDM-2.

Principles for the Development of the Second Edition of the PDM (PDM-2)

As members of the Steering and Scientific Committees for PDM-2, we have devised a preliminary set of guidelines for the PDM revision process that are straightforward, easy to implement, and designed to increase substantially the likelihood that the product of our efforts will be empirically rigorous, clinically useful, and viewed positively by clinicians of varying theoretical orientations. Five principles guide the work. 1. Transparency. All aspects of the PDM-2 revision process will be transparent and periodically accessible to professional colleagues. New instruments for assessing PDM-2 related constructs are available to the professional community at no cost. 2. Inclusiveness. We invite colleagues to contribute to the PDM-2 revision effort by offering input and critical feedback. We invite colleagues to contact any of us if questions or concerns arise and to send us papers or works in progress that they think might be useful in shaping our discussions and debates. 3. Flexibility. Although members of the PDM-2 Steering and Scientific Commit- tees are of one mind in assuming that psychodynamic processes play a role in all forms of psychopathology, there is also a clear recognition that some symptoms and syndromes are more strongly influenced than others by psychodynamic elements. For example, certain forms of personality pathology (e.g., narcissistic, histrionic) seem to be driven primarily by psychodynamic processes; in others (e.g., schizotypal) psychodynamic processes may play a less prominent role. 4. Empirical rigor. In order for PDM-2 to have a firm empirical foundation, we

This document is copyrighted by the American Psychological Association or one of its allied publishers. will conduct comprehensive surveys of the literature, including studies from

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. outside psychoanalysis, to obtain as complete a picture as possible of what we know about normal and pathological functioning. 5. Clinical utility. The raison d=etre of any diagnostic system is its usefulness in clinical settings. No matter how empirically rigorous and precise they may be, diagnostic criteria and syndrome descriptions are only helpful if they enhance the work of the practicing clinician and thereby improve the lives of patients. We seek to find a better balance between empiricism and clinical utility. Strategies To turn our vision into reality, we have inaugurated a four-step process for implementing these principles. PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 101 First, we are developing ways to collaborate across groups. By creating a mechanism through which different PDM-2 work groups communicate with each other about their initial proposals, we hope that active exchange of information can take place as new proposals are developed and refined. Not only will this cross-communication provide a broader clinical and empirical context for each work group’s discussions, but it also affords the possibility of collaborative work on syndromes that have implications for more than one part of the manual. We believe that no theoretical framework—psychoanalysis included—can provide a complete picture of the intra- and interpersonal dynamics that characterize a particular syndrome or set of syndromes. Accordingly, we seek input from clinicians of various theoretical orientations. As a number of writers have pointed out, most disorders are best understood as reflecting a combination of factors—investigated in psychodynamic, cognitive, biological, and cultural studies—and it is only when these perspectives are integrated that a nuanced understanding of a given syndrome can emerge. The PDM-2 will seek feedback from researchers in other specialty areas. Although ongoing discussions with clinicians and clinical researchers of varied backgrounds and theoretical allegiances can go a long way toward ensuring that diagnostic categories and descriptors are consistent with prevailing evidence from within and outside psychoanalysis, we must also ensure that PDM-2 is consistent with current research in neuroscience, developmental psychology, memory, social cognition, and other areas. We aim to engage constituents and stakeholders. A decade ago, Sadler and Fulford (2004) raised the question of whether patients and their families should play a role in the DSM-5 revision process. This is a worthwhile question for PDM-2 as well. Beyond the advantages and disadvantages of soliciting feedback from consumers of psychological services, it raises a broader issue—the degree to which input from various stakeholders (e.g., patients, policymakers, other health care professionals) would enhance future versions of the PDM. To be sure, there are tradeoffs (e.g., it is important to guard against bias from powerful, economically motivated groups), but to the degree that constituents and stakeholders are engaged in the development of PDM-2 the manual can benefit from their experience and expertise. In turn, these constituents and stakeholders may ultimately feel an increased ownership of, and commitment to, the manual.

PDM-Derived Empirical Tools

Although the PDM has earned respect from both psychodynamic and nonpsychodynamic practitioners (Gordon, 2008, 2009), it is in danger of being underutilized because it lacks

This document is copyrighted by the American Psychological Association or one of its allied publishers. easily usable assessment instruments. To help remedy this, we developed two user- This article is intended solely for the personal use of the individual user and is not to be disseminatedfriendly broadly. tools: the Psychodiagnostic Chart (PDC) and the Psychodynamic Diagnostic Prototypes (PDP).

The Psychodiagnostic Chart (PDC) The two forms of the PDC (Gordon & Bornstein, 2012) would operationalize the entire adult and children/adolescent sections of the PDM. The chart has been developed to be idiographic, flexible, and useful for practitioners of various theoretical orientations, to have a distinct dimension of personality structure, and to integrate the PDM with the symptom classifications of the DSM or ICD. The PDC has been developed on the basis of the PDM (first edition) structure and will be modified according to the PDM-2 changes. 102 LINGIARDI ET AL. The PDC is both a categorical and a dimensional chart. All dimensional ratings range from 1 (most disturbed)to10(healthy). It comprises five sections. (a) Personality organization: The PDC uses the mental capacities of the P Axis of the PDM (e.g., identity, object relations, affect tolerance, affect regulation, superego integration, reality testing, ego resilience) to assess level of severity. In the first step, the clinician rates each of the capacities from 1 (severe)to10(healthy). Then, considering all the ratings, the clinician rates the person’s overall personality structure from 1 (psychotic)to10(healthy). (b) Personality patterns: This section reviews the personality patterns/disorders described in the P Axes. The clinician begins by checking off as many descriptors as may apply to the client. He or she then infers the most dominant personality pattern or disorder and rates the level of severity (1Ð10). (c) Mental functioning: The clinician rates from 1 to 10 the descriptions of a person’s core mental capacities. Then he or she rates the patient’s overall mental functioning using a similar scale, ranging from 1 (severe defects)to10(optimal). (d) Symptoms: The clinician lists as many as four symptoms or subjective complaints and rates their degree of severity from 1 (severe)to10(mild). (e) Cultural-contextual issues: This is a qualitative section where the practitioner may consider how cultural or contextual factors may contribute to the symptoms. We initially assessed the utility of the PDC by surveying practitioners from various psychology listservs and Web sites who considered themselves expert in diagnostics. We asked them to complete an online survey after using the PDC with at least one client. We looked at the data when we had 50 completed surveys. Half of the respondents identified themselves as not psychodynamic. Sixty-eight percent of the practitioners rated the PDM Personality Organization as helpful to very helpful, 58% rated PDM Mental Functioning as helpful to very helpful, and 44% rated PDM Dominant Personality Patterns or Disorders as helpful to very helpful. In contrast, only 18% of the practitioners rated DSM GAF scores as helpful to very helpful, and just 14% rated ICD or DSM symptoms as helpful to very helpful. These preliminary results lend strong support for the PDC among experts (Bornstein & Gordon, 2012). After considering them, we dropped the GAF section and added a qualitative cultural/contextual dimension to the PDC. These survey results were recently replicated with a sample of 511 mental health practitioners with very similar findings, that is, personality organization rated the highest, and the ICD or DSM symptom classification rated the least helpful in understanding their clients (Gordon et al., 2013). We then worked to test the testÐretest reliability and construct validity of the PDC. We asked 38 psychologists who had frequently used the Minnesota Multiphasic Personality Inventory (MMPI)-2 during the last 12 months with psychotherapy patients, disability patients, or forensic clients to participate in a study on diagnoses. They were asked to rate their last 10 clients with both the PDC and MMPI. Of the 38 psychologists, 15 sent in a

This document is copyrighted by the American Psychological Association or one of its allied publishers. total of 98 PDCs and MMPI-2s. The PDC had very good 2-week retest stability.

This article is intended solely for the personal use of the individual user and is not to be disseminatedTestÐretest broadly. reliability was .92 (p Ͻ .001) for the Overall Personality Organization scale, was .89 (p Ͻ .001) for Overall Severity of Personality Disorder, ranged from .77 to .89 (p Ͻ .001) for the nine Mental Functioning, and was .87 (p Ͻ .001) for Severity of Symptoms. All the PDC constructs had good correlations with the MMPI-2 scores in the predicted direction (Gordon & Stoffey, 2014). The MMPI-2 scales of Schizophrenia (Sc), Hysteria (Hy), and Ego Strength (Es) indicated good construct validity for the distinct categorical components of psychotic, borderline, and neurotic levels of Personality Organization. The categories were derived by dividing the 10-point Overall Personality Organization scale into psychotic (ratings 1Ð3, n ϭ 13), borderline (4Ð6, n ϭ 52), and neurotic (7Ð10, n ϭ 33) levels. We predicted that the Sc scale mean at the psychotic level should be PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 103 significantly larger than both the Hy and Es scale means for the psychotic level. Pairwise comparisons supported that prediction: Sc was significantly larger than Es (M ϭ 85.77, SD ϭ 19.55 vs. M ϭ 34.31, SD ϭ 6.78, p ϭ .001) and significantly larger than Hy (M ϭ 85.77, SD ϭ 19.55 vs. M ϭ 72.69, SD ϭ 18.46, p ϭ .017). For the borderline level, we predicted that both the Sc scale mean and the Hy scale mean should not be significantly different, but they both should be significantly larger than the Es scale mean. That prediction was supported: Sc and Hy were not significantly different, but Sc was significantly larger than Es (M ϭ 62.21, SD ϭ 12.31, vs. M ϭ 43.58, SD ϭ 10.25, p ϭ .001) and Hy was also significantly larger than Es (M ϭ 64.21, SD ϭ 12.31 vs. M ϭ 43.58, SD ϭ 10.25, p ϭ .001). Finally, for the neurotic level, we predicted that the Es, Sc, and Hy scales should all be in the normalÐmoderate range. Hy and Sc were in the moderate range, and ego strength moved up to the average range, showing support for the prediction. Taken together, the analyses lend strong support to the construct validity of the Overall Personality Organization scale of the PDC. They specifically support the conclusion that personality patterns can exist on a continuum from neurotic to psychotic levels (see Figure 1). These analyses support Kernberg’s (1984) and McWilliams’s (2011b) positions that personality organization is an important (arguably the most important) dimension by which to understand overall psychopathology and mental suffering. This position was recently empirically supported by the review conducted by Koelen et al. (2012). We found also that expert practitioners of various theoretical orientations (most of whom were not psychodynamically oriented) felt that personality organization is a very important dimension in understanding their patients, and that personality patterns express themselves across the range of personality structure. The conviction of the members of the Personality This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Figure 1. MMPI-2 Hysteria (Hy), Schizophrenia (Sc), and Ego Strength (Es) Scales within the Psychotic, Borderline, and Neurotic categories of the Personality Organization Scale. Solid line at MMPI-2 score of T50 is average. Dotted line at T65 indicates clinically signiﬁcant scores. Psychotic (ratings 1Ð3, n ϭ 13), Borderline (4Ð6, n ϭ 52), and Neurotic (7Ð10, n ϭ 33). Psychotic: Sc ϾϾ Hy Ͼ Es; Borderline: (Sc ϳ Hy) Ͼ Es; Neurotic: (Sc ϳ Hy) Ͼ Es all in the average to moderate range. Hy: Psychotic Ͼ Neurotic. Sc: Psychotic ϾϾ (Borderline ϳ Neurotic). Es: Neurotic ϾϾ Psychotic; Neurotic Ͼ Borderline; Borderline Ͼ Psychotic. MMPI ϭ Minnesota Multiphasic Personality Inventory; T ϭ T- scores: standard scores with a mean of 50 and a standard deviation of 10. 104 LINGIARDI ET AL. Task Force of the original PDM that personality should be assessed as a ﬁrst step in diagnoses has thus received considerable empirical support and therefore will be a primary, distinct dimension or axis in PDM-2.

The Psychodynamic Diagnostic Prototypes (PDP) The PDP (Gazzillo, Lingiardi, & Del Corno, 2012), consists of 19 prototypic descriptions of personality disorders, one for each disorder included on the P Axis of the PDM. The aim of the PDP is to help clinicians and researchers use the P Axis even without a previous knowledge of the PDM. For this reason, the authors have taken the PDM descriptions of all the Axis P disorders, deleted the reference to articles and books presented in manual, and reformulated those parts of the PDM personality descriptions that were too theoret- ically laden or too inferential. In order to operationalize these theoretical concepts, the authors then took into account well validated dynamic assessment tools such as the Defense Mechanisms Rating Scale (Perry, 1990) and the Analytic Process Scales (Wal- dron et al., 2004). The clinician/rater who uses the PDP assesses on a 1Ð5 rater scale the degree to which the patient resembles one or more PDP prototypes. A score of 1 means no resemblance, while a score of 5 means a complete match between the patient’s clinical presentation and the prototypical description of that personality disorder; thus, with a score of 4 or 5, it is possible to make a categorical diagnosis of the disorder (see also Spitzer, First, Shedler, Westen, & Skodol, 2008). After having completed the construction of the PDP, the authors asked seven raters, clinical psychologists who had completed a 12-hr training on the PDM, to assess on a 1Ð5 Likert scale in what measure each of the PDP prototypes resembled the description of the same disorder given in the PDM. In 90% of the cases, the PDP prototypes were assessed as good or very good descriptions of PDM Axis P disorders. The PDP, thus, seems to have good face validity. The second step of the validation of the PDP was the assessment of interrater reliability (IRR) with respect to both dimensional (1 to 5) and categorical (diagnosis given/not given) assessment. In order to assess these IRR values, the authors collected the PDP assessments of 200 Italian patients. All were independently assessed with PDP by their treating clinicians and by one of our 7 PDM-trained raters. Clinicians had been following the patients assessed for an average 67.9 sessions (SD ϭ 86.5; ranging from 2 to 576 sessions), while the raters assessed the personalities of these patients via the Clinical Diagnostic Interview (Westen & Muderrisoglu, 2003), a systematic interview for personality assessment. The average Cohen’s kappa for the PDP prototypes categorically ϭ ϭ

This document is copyrighted by the American Psychological Association or one of its allied publishers. assessed (4 and 5 presence of the disorder; 1, 2, or 3 no disorder) was .61. The

This article is intended solely for the personal use of the individual user and is not to be disseminatedaverage broadly. intraclass correlation coefficient of the PDP prototypes dimensionally assessed was .74. Thus, the IRR of PDP ranges from good to excellent. For assessing the concurrent and discriminant validity of the PDP, we have used as criterion measures the DSM–IV Axis II personality diagnoses of our patients as assessed by the raters with the Axis II checklist. This checklist, developed by Drew Westen (2002), is a clinician report instrument that combines a categorical and dimensional assessment of each of the Axis II criteria and disorders. For the categorical DSM diagnoses, we have followed the diagnostic thresholds of DSM–IV Axis II, and we have averaged the PDP assessment of clinicians and raters before comparing them with DSM diagnoses. Given that in Axis II, we have only nine disorders analogous to the PDM Axis P diagnoses, we have concurrent and discriminant validity data on only nine of our PDP prototypes. The PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 105 average correlation between the PDP and the analogous DSM disorder is .62, while the average correlation between the PDP prototype and a different DSM disorder is .05. On this basis as well, we can say that the concurrent and discriminant validity of our PDP is generally good. To assess the construct validity of the PDP, we have used a stepwise model of linear regression to capture the relationships between the different PDM P Axis disorders and their specific core preoccupations and pathogenic beliefs. To this end, we developed two different clinician report instruments: the Core Preoccupation Questionnaire (Gazzillo & Lingiardi, 2008) and the Pathogenic Belief Questionnaire (Lingiardi & Gazzillo, 2008). These instruments ask the raters/clinicians to assess on a 1Ð7 Likert scale the degree to which the motivations, cognitions, emotions and behaviors of a patient reflect each of the 16 preoccupations and 36 beliefs about self and others described in the PDM P Axis. Our data show that 14 of the 16 core preoccupations and 21 of the 36 pathogenic beliefs are specifically connected with the disorder predicted by the PDM. Consequently, we have added to our PDP descriptions the core preoccupations and pathogenic beliefs described in the manual. Finally, we have assessed the concurrent validity of the PDP with respect to some life history information collected by our raters with the Clinical Data Form (Westen & Shedler, 1999a). In this case as well, we have used a stepwise model of linear regression and we have chosen only objective data as predictors. We have found, for example, that the number of arrests and violent crimes committed by adolescents are predicted by their level of psychopathy; health problems are correlated with somatizing personality features, physical abuse in childhood correlates with masochistic personality patterns, and quality of social relationships is inversely correlated with the schizoid features. On the basis of these data, we can say that PDP is a reliable and valid instrument for the assessment of personality with the PDM P Axis categories. Given that it needs no more than 30 min to be scored, we think that it is user-friendly enough to be utilized in real clinical practice, including public settings. There follows one of the PDP prototypes: PDP Psychopathic Personality Disorder Prototype

Psychopathic individuals manipulate others and are afraid of being manipulated by them. They tend to feel rage and envy, think they can do anything they want, and believe that everyone is selﬁsh, manipulative, and dishonorable. For these reasons, they tend to control other people in a persistent and pervasive way and to use their power for their own sake. Psychopathic people seem to care more about themselves than other people, and tend to feel anxiety less frequently or intensely than others. In addition, they need constant stimulation. They seem to lack a moral center of gravity, but may be charming and charismatic and able

This document is copyrighted by the American Psychological Association or one of its allied publishers. to read others’ emotional states with great accuracy, being hyperacute to their surroundings.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. However, their emotional life tends to be impoverished, and their expressed affect often is insincere and intended to manipulate other people. They lack the capacity to describe their own emotional reactions with any depth or nuance, and they frequently somatize. Their emotional connection to others is minimal, typically they lose interest in people they see as no longer useful to them, and they tend to be self-centered and manipulative. Individuals who match this prototype lack remorse and tend to devalue love and kindness, considering these feelings childish and illusory. Some are actively aggressive, explosive and predatory; others seem passive, more dependent, nonaggressive and relatively nonviolent, but in any case they are manipulative and ready to exploit others.

We are currently completing an international research project with a large sample of practitioners aimed at investigating the relationships between the PDC and the PDP 106 LINGIARDI ET AL. categories, defense mechanisms (with the Defensive Functioning Scale; American Psy- chiatric Association, 2000), and countertransference patterns (with the Countertransfer- ence Questionnaire; Betan, Heim, Zittel, & Westen, 2005; see also Colli, Tanzilli, Dimaggio & Lingiardi, 2014). Finally, in a recent study we have investigated the emotional responses of the therapists associated to the level of personality organization (assessed with the PDC) and the PDM personality patterns/disorders (assessed with the PDP) of the patients in treatment (Gazzillo et al., in press). We are particularly interested in the implications of each of these diagnostic elements on the structuring of the therapeutic setting.

The Construction of PDM-2

The PDM-2 project would never have been achieved without its conceptual father, Stanley Greenspan (1941Ð2010), whom we view as “our Magellan who has given us the road map,” and Nancy Greenspan, a responsive and devoted caretaker of her late husband’s legacy. The first steps toward the new edition required a steering committee representing both continuity and change. Robert Wallerstein (Honorary Chair), Nancy McWilliams, and Vittorio Lingiardi have agreed to comprise that group. At the time of publication of this article, the sponsoring organizations for the second edition are the International Psychoanalytical Association, the International Association for Relational Psychoanalysis and Psychotherapy, the Division of Psychoanalysis (39) of the American Psychological Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the American Association for Psychoanalysis in Clinical Social Work, and the Italian Group for the Advancement of Psychodynamic Diagnosis and Research. The American Psychoanalytic Association has been contacted to renew its sponsorship as in the first edition. For the drafting of the different sections of the manual, seven specific Task Forces have been considered: (a) Adults, (b) Adolescents, (c) Children, (d) Infancy and Early Childhood, (e) Elderly, (f) PDM-2 Empirical Tools, (g) Case Illustrations and PDM-2 Profiles.1 Many contributors to the first edition are involved, with the collaboration of some new scholars.

Perspectives There are two key purposes for the next edition. First, we need to enhance dialogue between PDM diagnosis and other diagnostic systems, in particular the DSM and the ICD.

This document is copyrighted by the American Psychological Association or one of its allied publishers. Like the original PDM, PDM-2 is not intended to replace these descriptive nosologies, but

This article is intended solely for the personal use of the individual user and is not to be disseminatedto broadly. provide an overarching framework of personality structure and mental functioning within which the neo-Kraepelinian symptom classiﬁcations can be understood and more

1 We are already able to list the Steering Committee (Vittorio Lingiardi, Nancy McWilliams, and Robert Wallerstein [Honorary Chair]) and the section editors of the specific sections: P Axis Adults (Nancy McWilliams and Jonathan Shedler), M Axis Adults (Robert F. Bornstein and Vittorio Lingiardi), S Axis Adults (Emanuela Mundo and John O’Neil), Adolescents (Nick Midgley and Mario Speranza), Children (Norka Malerg and Larry Rosenberg), Infancy and Early Childhood IEC (Linda Mayes and Anna Maria Speranza), Elderly (Franco Del Corno and Daniel Plotkin), Tools (Francesco Gazzillo, Robert M. Gordon, and Sherwood Waldron), and Case Illustrations and PDM-2 Profiles (Franco Del Corno, Vittorio Lingiardi, and Nancy McWilliams). PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 107 effectively treated. Furthermore, PDM-2 will involve more systematic and empirical research than the first edition included, especially as such research informs more operationalized descriptions of the different disorders (Huprich et al., in press). Although the second edition will conserve the main structure of the first PDM, it will be characterized by several important changes.

P Axis In the P Axis of the Adult section, Blatt’s (2008) conceptualization of two key configurations of psychopathology, anaclitic and introjective, will be examined in greater depth with relevance to difference personality types. According to Blatt, introjective issues, centered on problems about the definition of one’s identity, seem mainly present in schizoid, schizotypal, paranoid, narcissistic, antisocial and obsessive personality disorders, while anaclitic issues, related to the need to develop more stable and mutual object relations, seem more prevalent in borderline, histrionic, and dependent personality disorders (Blatt, 1990, 1995). The first PDM incorporated Blatt’s work in noting introjective (self-definition) and anaclitic (self-in-relation) subtypes of personality types, but since its publication, more research has been done on these core polarities of personality. This conceptualization seems highly relevant to which kinds of psychotherapy may be most effective in relation to the specific difficulties of different patients. In order to connect PDM-2 more closely with empirical research, the section on level of personality organizations will be integrated and reformulated according to the empirical results from measures such as the Shedler-Westen Assessment Procedure (SWAP)-200 (Westen & Shedler, 1999a, 1999b), the Structured Interview of Personality Organization (Clarkin, Caligor, Stern & Kernberg, 2004), and the Karolinska Psychodynamic Profile (Weinryb, Rossel, & Asberg, 1991). As we previously noted, in the original PDM, there is a significant omission. Despite some authors’ arguments for the presence of a psychotic level of personality organization (e.g., Kernberg, 1984; McWilliams, 2011b; Wallerstein, 2006), the authors of the PDM considered that this formulation could lead to a terminological confusion with other syndromes, such as schizophrenia. This problem is not particular to the PDM; the same confusion inheres in the interesting fact that whereas the DSM-5 characterizes schizotypal personality as a personality disorder, the ICD-10 classifies it as a psychotic disorder. Gordon and Stoffey (2014), in support of McWilliams’s argument that personality organization exists along a continuum from psychotic through borderline to neurotic and healthy structures, have empirically demonstrated that even histrionic personality patterns can be expressed at the psychotic level of

This document is copyrighted by the American Psychological Association or one of its allied publishers. functioning (see Figure 1). It appears that schizophrenia and psychotic affective

This article is intended solely for the personal use of the individual user and is not to be disseminatedillnesses broadly. should not to be confused with a severe level of personality organization that can be present with any particular personality pattern. A separate axis of personality organization would also resolve the “schizotypal controversy” in that it would be classiﬁed a schizoid pattern at the psychotic level of personality organization. Such conceptualizations may demonstrate the PDM’s superiority to the DSM and ICD in the domain of personality taxonomy. The PDM-2 P Axis (Adults, Adolescents, Children, and Elderly) will also integrate and revise the section on types of personality disorders according to theoretical, clinical, and empirical indications from the clinical literature and according to clinically and empirically sound measures such as the SWAP-200 (Westen & Shedler, 1999a, 1999b) and its new versions and applications (SWAP-II; Blagov, Bi, Shedler, & 108 LINGIARDI ET AL. Westen, 2012; and SWAP-200-Adolescents; Westen, Shedler, Durrett, Glass, & Martens, 2003; see also Lingiardi, Shedler & Gazzillo, 2006; Gazzillo et al., 2013), and the PDP (Gazzillo, Lingiardi, & Del Corno, 2010). Moreover, we are considering the possibility of including an “emotionally dysregulated personality disorder,” cor- responding in part to the DSM’s description of “borderline personality disorder” (which is not included in the current list of PDM personality disorders, as the concept of “borderline” has been retained there in the meaning that originally arose from clinical experience: as a level rather than a type of personality organization). In other words, we may add a category that is more or less equivalent to the DSM’s borderline personality disorder rather than using the term strictly to denote borderline personality organization.

M Axis The number of mental functions comprising the M Axis of the Adult section will be increased from nine to 12: (a) capacity for regulation, attention, and learning; (b) capacity for affective range, communication, and understanding; (c) capacity for mentalization and reflective functioning; (d) capacity for differentiation and integration; (e) capacity for relationships and intimacy; (f) quality of internal experience, including level of confidence and self-regard; (g) impulse control and regulation; (h) defensive functioning; (i) adaptation, resiliency, and strength; (j) self-observing capacities (psychological mindedness); (k) capacity to construct and use internal standards and ideals; and (l) meaning and purpose. Compared to the first edition of the manual, the PDM-2 labels and descriptions of mental functioning have been revised and reformulated in a clinician-friendly, empirically grounded, and assessment-relevant way. Moreover, the M Axis will explicitly conceptualize personality and mental functioning as resulting from the integration of nature (temperament, genetic predisposition, basic underlying traits) and nurture (learning, experience, attachment style, cultural and social context). To facilitate clinically useful diagnosis and case conceptualization, it is essential that assessment of the M Axis capacities yield practically applicable results with utility for diagnostic formulation, and treatment planning and implementation. Given that it is also essential that clinicians across orientations are able to assess M Axis capacities in a reliable and valid manner, for each capacity we will provide a list of well validated clinical tools that can be employed to aid in assessment. These lists of tools include, among others, the SWAP-200 (Westen & Shedler, 1999a, 1999b), the Defense Mechanism Rating Scale (Perry, 1990), the Social Cognition and Object Relations Scale (Westen, 1995), the Object Relations Inventory (Blatt & Auerbach, 2001), and the Reflective Functioning Scale (Fonagy, Steele, Steele, & Target, 1997). Moreover, we will revise and reformulate the “illustrative descriptions This document is copyrighted by the American Psychological Association or one of its allied publishers. of the range and adequacy of functioning” in a way that is more clinician-friendly, This article is intended solely for the personal use of the individual user and is not to be disseminatedempirically broadly. grounded, and assessment-relevant, by introducing an assessment procedure with a Likert-style scale (i.e., indicating in a quantitative way the level at which any single mental function is articulated).

S Axis Regarding the S Axis of the Adult section, we will enhance its integration with the more symptomÐsyndrome-oriented diagnostic manuals such as the DSM and the ICD. We will try not to exclude any relevant syndrome or psychopathological condition (e.g., panic disorder or hypochondriasis, which are not included in the PDM current list of symptom’s patterns). Finally, we will give a more exhaustive explanation of the rationale for the PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 109 description of “affective states,” “cognitive patterns,” “somatic states,” and “relationship patterns,” and we will reference related clinical and empirical studies. Greater attention will be also paid to the subjective experiences of the clinician (countertransference). The section dedicated to the Classification of Child and Adolescent Mental Health Disorders will also be subject to some changes. First of all, we intend to separate the Adolescent section (age 11Ð18) from the Child section (4Ð10), because it seems clinically naive to use the same levels and patterns for describing the mental functioning of, say, a 4-year-old child and a 14-year-old adolescent. The idea of assessing, in adolescence, first Mental Functioning (M Axis) Axis) and then Personality (P Axis) patterns will be maintained. Regarding the Special Section on Infancy and Early Childhood Mental Health Dis- orders, we will add a specific section on developmental lines and homotypic/heterotypic continuities of early infancy, childhood, adolescent and adult psychopathology, which are objects of investigation in the clinical and empirical literature (see, e.g., Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Speranza & Fortunato, 2012). We will give better definitions of the quality of primary relationships (between the child and his or her caregivers), adding contributions from theoretical, clinical and empirical investigations into infant research and attachment theory (see Cassidy & Shaver, 2008), and we will make references to empirically grounded instruments useful for their assessment. Starting from this perspective, we will also emphasize more strongly the evaluation of family systems and their characteristic relational patterns, including a paragraph about attachment patterns and their possible relationship to psychopathology and normative development. An important change in the incoming new version of the manual will be the inclusion of a section on Mental Health Disorders of the Elderly, which was not in the first edition. As McWilliams (2011a) pointed out,

One of the ﬁrst serious criticisms of the PDM embarrassed us: Daniel Plotkin (personal communication, December 2006) at UCLA Medical Center wondered why, in this avowedly developmental document, we included sections on infancy, childhood, and adulthood, but none on the elderly. In view of the average age of the steering committee members (late 60s and early 70s, by my calculation), one can only infer massive denial: Including a section on elderly patients never occurred to us! (p. 120)

Moreover, in the PDM-2 we have decided to eliminate the section Conceptual and Empirical Foundations for a Psychodynamically Based Classiﬁcation System for Mental Health Disorders and to include a new section on assessment tools. Within this section we will include (a) the PDM derived instruments, such as the PDP and PDC, with their This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminatedmanuals; broadly. (b) the description, strengths, limitations and main references of empirical instruments that shaped the PDM categories (such as SWAP, Structured Interview of Personality Organization, Karolinska Psychodynamic Profile, and Social Cognition and Object Relations Scale); (c) the description, strengths, limitations, and main references of widely utilized tools, both self-report and performance-based (e.g., MMPI, Thematic Apperception Test, Rorschach Inkblot Measure), that can be a useful aid in the assessment of some of the PDM dimensions; (d) the description, strengths, limitations, and main references of empirical tools useful for the assessment of patient and therapist contributions to psychotherapy process (e.g., the Analytic Process Scales, the Psychotherapy Process Q-Set; Ablon & Levy, 2009; Jones, 2000; the Comparative Psychotherapy Process Scale; Hilsenroth, Blagys, Ackerman, Bonge, & 110 LINGIARDI ET AL. Blais, 2005). The aims of this section are to improve the dialogue between clinical practice and research, to guide the practitioners in the selection of empirical tools that can help them to refine and support PDM assessment, both for clinical and research purposes, and to help to bridge the gap between research on personality and research on psychotherapy process and outcome. Finally, PDM-2 will contain a special section dedicated to clinical exemplifications, which will help the reader to have a better and deeper understanding of the manual’s contents. Our aim is to provide clinical illustrations that exemplify how the PDM assessment procedures can help therapists to understand and describe the mental functioning of real patients, both their positive resources and their pathological dimensions. Together with the PDM (P Axis, M Axis, and S Axis) and the ICD and DSM-5 diagnoses, PDM-2 clinical presentations should articulate what are the more relevant affects, defense mechanisms, and conflicts of the patients, their specific core preoccupations and pathogenic beliefs, and the affective reactions experienced by the assessor while interacting with them. Emphasis will be on patients’ resources and strengths, not just limitations and pathology. Case presentations deriving from PDM-2 will specify the more and less compromised mental processes of the patient and in what circumstances the person functions at higher and lower levels, respectively.

Conclusion: A Historic Opportunity

As McWilliams (2011a) has noted, the primary goals for the PDM were to create a diagnostic system that embraced the complexities of human experience (both normal and pathological) and to conceptualize the major psychological disorders in ways that went beyond external description to capture the subjective phenomenology and underlying dynamics that shape psychological symptoms and syndromes. As we have noted, in the last 2 decades, there has been an increasing tendency to deﬁne mental problems primarily on the basis of observable symptoms, behaviors, and traits, with overall personality functioning and levels of adaptation noted only secondarily. There is increasing evidence, however, that both mental health and psychopathology involve many subtle features of human functioning, including affect tolerance, regulation, and expression; coping strategies and defenses; capacities for understanding self and others; and quality of relationships. Mounting evidence from neuroscience and developmental studies supports the position that mental functioning, whether optimal or compromised, is highly complex. To ignore mental complexity is to ignore the very phenomena of concern to therapists and students of human psychology. After all, our mental com-

This document is copyrighted by the American Psychological Association or one of its allied publishers. plexity deﬁnes our most human qualities.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Greenspan thought that the PDM could serve as a holistic diagnostic tool. He believed it could help not only psychodynamically oriented clinicians, but also behavioral, cognitive, humanistic, emotion-focused, family, systems, and biologically oriented therapists “understand their patients more fully . [. . .] We’ve seen interest from people in anthropology, sociology, educators, legal scholars and people in the justice system,” he noted. “It’s broad- ened the purview of psychology to reach into all the related disciplines that deal with human beings” (Packard, 2007, p. 30). The PDM has a historic opportunity to expand beyond the doctor’s office and the symptom checklist into the deeper complexities of the human being. To be trapped between the anonymity of rating scales and the challenges of self-referential jargon not only mortifies the clinician’s professional identity, but also dims or distorts PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 111 practitioners’ abilities to detect and describe their patients’ characteristic mental experiences—and, therefore, the capacity to relieve their psychological distress. Without a counterpoint to the current tendency to focus more and more narrowly and discretely on disorder categories, the clinical relationship may be jeopardized and even damaged beyond repair. This danger is the main reason we feel we need a biopsychosocial classification system such as the PDM. It also is the main reason we are committed to improving its clinical value with a new edition. With it, we hope to fulfill Robert Wallerstein’s (personal communication, 2012) wish “that PDM will have an enduring life.”

References Ablon, J. S., & Levy, R. (2009). Psychotherapy process Q-set. Coding manual revised. Unpublished manuscript, University of California, Berkeley. American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders (1st ed.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Defensive Functioning Scale. Diagnostic and statistical manual of mental disorders: DSM-IV-R, Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Batstra, L., & Frances, A. (2012). Holding the line against diagnostic inflation in psychiatry. Psychotherapy and Psychosomatics, 81, 5Ð10. http://dx.doi.org/10.1159/000331565 Betan, E., Heim, A. K., Zittel Conklin, C., & Westen, D. (2005). Countertransference phenomena and personality pathology in clinical practice: An empirical investigation. American Journal of Psychiatry, 162, 890Ð898. Blagov, P. S., Bi, W., Shedler, J., & Westen, D. (2012). The Shedler-Westen assessment procedure (SWAP): Evaluating psychometric questions about its reliability, validity, and impact of its fixed score distribution. Assessment, 19, 370Ð382. http://dx.doi.org/10.1177/1073191112436667 Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the therapeutic process. Washington, DC: American Psychological Association Press. Blatt, S. J. (1990). Interpersonal relatedness and self-definition: Two personality configurations and their implications for psychopathology and psychotherapy. In J. L. Singer (Ed.), Repression and dissociation: Implication for personality theory, psychopathology and health (pp. 299Ð335). Chicago, IL: University of Chicago Press. Blatt, S. J. (1995). Representational structures in psychopathology. In D. Cicchetti & S. Toth (Eds.), Rochester symposium on developmental psychopathology, vol. VI: Emotion, cognition and representation (pp. 1Ð33). Rochester, NY: University of Rochester Press.

This document is copyrighted by the American Psychological Association or one of its allied publishers. Blatt, S. J., & Auerbach, J. S. (2001). Mental representation, severe psychopathology, and the

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. therapeutic process. Journal of the American Psychoanalytic Association, 49, 113Ð159. http:// dx.doi.org/10.1177/00030651010490010201 Bornstein, R. F. (2010). Psychoanalytic theory as a unifying framework for 21st century personality assessment. Psychoanalytic Psychology, 27, 133Ð152. http://dx.doi.org/10.1037/a0015486 Bornstein, R. F. (2011). Reconceptualizing personality pathology in DSM-5: Limitations in evidence for eliminating dependent personality disorder and other DSM–IV syndromes. Journal of Personality Disorders, 25, 235Ð247. http://dx.doi.org/10.1521/pedi.2011.25.2.235 Bornstein, R. F., & Gordon, R. M. (2012). What do practitioners want in a diagnostic taxonomy? Comparing the PDM with DSM and ICD. Division/Review: A Quarterly Psychoanalytic Forum, 6, 35. Cassidy, J., & Shaver, P. R. (2008). Handbook of attachment (2nd ed.): Theory, research, and clinical applications. New York, NY: Guilford Press. 112 LINGIARDI ET AL.

Clarkin, J., Caligor, E., Stern, B. L., & Kernberg, O. F. (2004). The Structured Interview of Personality Organization (STIPO). Unpublished manuscript. New York, NY: Personality Dis- orders Institute/Weill Medical College of Cornell University. Clegg, J. W. (2012). Teaching about mental health and illness through the history of the DSM. History of Psychology, 15, 364Ð370. http://dx.doi.org/10.1037/a0027249 Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. The American Journal of Psychiatry, 171, 102Ð108. http://dx.doi.org/10.1176/appi.ajp.2013.13020224 Cooper, R. (2004). What is wrong with the DSM? History of Psychiatry, 15, 5Ð25. http://dx.doi.org/ 10.1177/0957154X04039343 Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psy- chiatry, 60, 837Ð844. http://dx.doi.org/10.1001/archpsyc.60.8.837 Craddock, N., & Owen, M. J. (2010). The Kraepelinian dichotomy: Going, going...Butstill not gone. The British Journal of Psychiatry, 196, 92Ð95. http://dx.doi.org/10.1192/ bjp.bp.109.073429 Del Corno, F., & Lingiardi, V. (2012). The Psychodynamic Diagnostic Manual (PDM) in the U.S.A. and in Europe: Between commercial success and inﬂuence on professionals and researchers. Bollettino di Psicologia Applicata, 265, 5Ð10. Dunn, P. B. (2008). Book reviews: Psychodynamic Diagnostic Manual. Journal of the American Psychoanalytic Association, 56, 631Ð638. http://dx.doi.org/10.1177/0003065108319735 Ferrari, H. (2006). [Psychodynamic Diagnostic Manual, PDM]. Vertex (Buenos Aires, Argentina), 17, 356Ð361. Ferrari, H., Lancelle, G., Pereira, A., Roussos, A., & Weinstein, L. (2008). El Manual Diagnostico Psicoanalìtico. Discusiones sobre su estructura, su utilidad y viabilidad. Reportes de Investi- gatiòn, 1, Universidad de Belgrano. Retrieved from http://www.ub.edu.ar/investigaciones/ ri_nue-vos/1_rep1.pdf Fonagy, P., Steele, M., Steele, H., Target, M. (1997). Reﬂective functioning manual, version 4.1, for application to Adult Attachment Interview. London: University College London. Frances, A. (2011). The constant DSM-5 missed deadlines and their consequences: The future is closing in. Psychiatric Times, 28, 14Ð15. Frances, A. (2013). Essentials of psychiatric diagnosis. New York, NY: Guilford Press. Ganellen, R. J. (2007). Assessing normal and abnormal personality functioning: Strengths and weaknesses of self-report, observer, and performance-based methods. Journal of Personality Assessment, 89, 30Ð40. http://dx.doi.org/10.1080/00223890701356987 Gazzillo, F., & Lingiardi, V. (2008). Core Preoccupations Questionnaire. (Unpublished manuscript). Sapienza University, Rome, Italy. Gazzillo, F., Lingiardi, V., & Del Corno, F. (2010). La valutazione della personalita` con i Prototipi Diagnostici Psicodinamici: Una ricerca empirica nata dalla collaborazione tra Universita` e Servizi pubblici. The personality assessment with the Psychodynamic Diagnostic Prototypes: A This document is copyrighted by the American Psychological Association or one of its allied publishers. research project in collaboration between Sapienza University of Rome and Public Health This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Services. Infanzia e adolescenza, 10, 101Ð112. Gazzillo, F., Lingiardi, V., & Del Corno, F. (2012). Towards the validation of three assessment instruments derived from the PDM P Axis: The psychodynamic diagnostic prototypes, the Core Preoccupations Questionnaire and the Pathogenic Beliefs Questionnaire. Bollettino di Psicologia Applicata, 265, 31Ð45. Gazzillo, F., Lingiardi, V., Del Corno, F., Genova, F., Bornstein, R. F., Gordon, R., & McWilliams N. (in press). Clinicians’ emotional responses and PDM P axis personality disorders: A clinically relevant empirical investigation. Psychotherapy: Theory, Research, & Practice. Gazzillo, F., Lingiardi, V., Peloso, A., Giordani, S., Vesco, S., Zanna, V.,...Vicari, S. (2013). Personality subtypes in adolescents with anorexia nervosa. Comprehensive Psychiatry, 54, 702Ð712. http://dx.doi.org/10.1016/j.comppsych.2013.03.006 PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 113

Good, E. M. (2012). Personality disorders in the DSM-5: Proposed revisions and critiques. Journal of Mental Health Counseling, 34, 1Ð13. Gordon, R. M. (2008). Early reactions to the PDM by psychodynamic, CBT and other psychologists. Psychologist–Psychoanalyst, 26, 53Ð59. Gordon, R. M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by psychodynamic, CBT and other non-psychodynamic psychologists. Issues in Psychoanalytic Psychology, 31, 52Ð62. Gordon, R. M., & Bornstein, R. F. (2012). The psychodiagnostic charts. Unpublished document. Retrieved from https://sites.google.com/site/psychodiagnosticchart/ Gordon, R. M., Gazzillo, F., Blake, A., Bornstein, R. F., Etzi, J., Lingiardi, V.,...Tasso, A. F. (2013). The relationship between theoretical orientation and assumptions about diagnoses, boundaries and countertransference. Manuscript submitted for publication. Gordon, R. M., & Stoffey, R. W. (2014). Operationalizing the psychodynamic diagnostic manual: A preliminary study of the psychodiagnostic chart. Bulletin of the Menninger Clinic, 78, 1Ð15. http://dx.doi.org/10.1521/bumc.2014.78.1.1 Halasz, G. (2008). In conversation with Dr. Nancy McWilliams. Australasian Psychiatry, 16, 397Ð404. http://dx.doi.org/10.1080/10398560802033037 Hansell, J. H., & Damour, L. K. (2008). Abnormal Psychology (2nd ed.). Hoboken, NJ: Wiley. Hilsenroth, M. J., Blagys, M., Ackerman, S., Bonge, D., & Blais, M. (2005). Measuring psychody- namicÐinterpersonal and cognitiveÐbehavioral techniques: Development of the Comparative Psychotherapy Process Scale. Psychotherapy: Theory, Research, Practice, Training, 42, 340Ð 356. http://dx.doi.org/10.1037/0033-3204.42.3.340 Huprich, S. K. (2011). Contributions from personality- and psychodynamically oriented assessment to the development of the DSM-5 personality disorders. Journal of Personality Assessment, 93, 354Ð361. http://dx.doi.org/10.1080/00223891.2011.577473 Huprich, S. K., Bornstein, R. F., & Schmitt, T. A. (2011). Self-report methodology is insufficient for improving the assessment and classification of Axis II personality disorders. Journal of Person- ality Disorders, 25, 557Ð570. http://dx.doi.org/10.1521/pedi.2011.25.5.557 Huprich, S. K., McWilliams, N., Lingiardi, V., Bornstein, R. F., Gazzillo, F., & Gordon, R. M. (in press). The Psychodynamic Diagnostic Manual (PDM) and the PDM-2: Opportunities to significantly affect the profession. Psychoanalytic Inquiry. Insel, T. (2013, April 29). Director’s blog: Transforming diagnosis. Retrieved from http:// www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml Jones, E. (2000). Therapeutic action: A guide to psychoanalytic therapy. Northvale, NJ: Jason Aronson. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Koelen, J. A., Luyten, P., Eurelings-Bontekoe, L. H., Diguer, L., Vermote, R., Lowyck, B., & Bühring, M. E. (2012). The impact of level of personality organization on treatment response: A systematic review. Psychiatry: Interpersonal and Biological Processes, 75, 355Ð374.

This document is copyrighted by the American Psychological Association or one of its allied publishers. Lingiardi, V., & Gazzillo, F. (2008). Pathogenic beliefs questionnaire. (Unpublished manuscript).

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Sapienza University, Rome, Italy. Lingiardi, V., Shedler, J., & Gazzillo, F. (2006). Assessing personality change in psychotherapy with the SWAP-200: A case study. Journal of Personality Assessment, 86, 23Ð32. http:// dx.doi.org/10.1207/s15327752jpa8601_04 Livesley, W. J. (2010). Confusion and incoherence in the classiﬁcation of personality disorder: Commentary on the preliminary proposals for DSM-5. Psychological Injury and Law, 3, 304Ð313. http://dx.doi.org/10.1007/s12207-010-9094-8 McWilliams, N. (2008). The Psychodynamic Diagnostic Manual: A clinically useful complement to DSM. Psychiatric Times, 25, 1Ð8. McWilliams, N. (2011a). The Psychodynamic Diagnostic Manual: An effort to compensate for the limitations of descriptive psychiatric diagnosis. Journal of Personality Assessment, 93, 112Ð122. http://dx.doi.org/10.1080/00223891.2011.542709 114 LINGIARDI ET AL.

McWilliams, N. (2011b). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). New York, NY: Guilford Press. Nussbaum, A. M. (2013). The pocket guide to the DSM-5 Diagnostic Exam. Washington, DC: American Psychiatric Publishing. OPD Task Force. (Ed.), (2001). Operationalized psychodynamic diagnostics (OPD): Foundations and manual. Kirkland, WA: Hogrefe & Huber. Packard, E. (2007). A new tool for psychotherapists. Five psychoanalytic associations collaborate to publish a new diagnostic manual. Monitor, 38, http://www.apa.org/monitor/jan07/tool.aspx PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Perry, C. J. (1990). Defense Mechanism Rating Scale (DMRS): 5th edition. Boston, MA: Author. Protopopescu, X., & Gerber, A. J. (2013). Bridging the gap between neuroscientific and psychodynamic models in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics of North America, 22, 1Ð31. http://dx.doi.org/10.1016/j.chc.2012.08.008 Ronningstam, E. (2011). Narcissistic personality disorder in DSM-V: In support of retaining a significant diagnosis. Journal of Personality Disorders, 25, 248Ð259. http://dx.doi.org/10.1521/ pedi.2011.25.2.248 Rosenthal, R. J. (2008). [Psychodynamic psychotherapy and the treatment of pathological gam- bling]. Revista Brasileira de Psiquiatria (São Paulo, Brazil), 30, S41ÐS50. http://dx.doi.org/ 10.1590/S1516-44462008005000004 Sadler, J. Z., & Fulford, K. W. M. (2004). Should patients and families contribute to the DSM-V process? Psychiatric Services, 55, 133Ð138. Shedler, J., Beck, A., Fonagy, P., Gabbard, G. O., Gunderson, J., Kernberg, O.,...Westen, D. (2010). Personality disorders in DSM-5. The American Journal of Psychiatry, 167, 1026Ð1028. http://dx.doi.org/10.1176/appi.ajp.2010.10050746 Speranza, A. M., & Fortunato, A. (2012). Infancy, childhood and adolescence in the diagnostics of the Psychodynamic Diagnostic Manual (PDM). Bollettino di Psicologia Applicata, 265, 53Ð65. Spitzer, R. L., First, M. B., Shedler, J., Westen, D., & Skodol, A. E. (2008). Clinical utility of five dimensional systems for personality diagnosis: A “consumer preference” study. The Journal of Nervous and Mental Diseases, 196, 356Ð374. http://dx.doi.org/10.1097/ NMD.0b013e3181710950 Stepansky, P. E. (2009). Psychoanalysis at the margins. New York, NY: Other Press. Task Force on Research Diagnostic Criteria: Infancy and Preschool. (2003). Research diagnostic criteria for infants and preschool children: The process and empirical support. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1504Ð1512. Turner, M. E., & Pratkanis, A. R. (1998). Theoretical perspectives on group think: A 25th anniversary appraisal. Organizational Behavior and Human Decision Processes, 73, 103Ð104. http://dx.doi.org/10.1006/obhd.1998.2768 Vanheule, S. (2012). Diagnosis in the field of psychotherapy: A plea for an alternative to the DSM-5.x. Psychology and Psychotherapy, 85, 128Ð142. http://dx.doi.org/10.1111/j.2044-

This document is copyrighted by the American Psychological Association or one of its allied publishers. 8341.2012.02069.x

This article is intended solely for the personal use of the individual user and is not to be disseminatedWaldron, broadly. S., Scharf, R. D., Hurst, D., Firestein, S. K., & Burton, A. (2004). What happens in a psychoanalysis? A view through the lens of the Analytic Process Scales (APS). The International Journal of Psychoanalysis, 85, 443Ð466. http://dx.doi.org/10.1516/5PPV-Q9WL-JKA9-DRCK Wallerstein, R. S. (2006). Psychoanalytically based nosology: Historic origins. In P. D. M. Task Force (Ed.), Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. Weinryb, R. M., Rossel, R. J., & Asberg, M. (1991). The Karolinska Psychodynamic Proﬁle: 1. Validity and dimensionality. 2. Interdisciplinary and cross-cultural reliability. Acta Psychiatrica Scandinavica, 83, 64Ð76. Westen, D. (1995). Social Cognition and Object Relations Scale: Q-sort for Projective Stories (SCORS-Q). Unpublished manuscript. Cambridge, MA: Cambridge Hospital and Harvard Med- ical School. PSYCHODYNAMIC DIAGNOSTIC MANUAL VERSION 2 115

Westen, D. (2002). Clinical diagnostic interview. Unpublished manual, Emory University. Re- trieved October 4, 2007, from www.psychsystems.net/lab Westen, D., & Muderrisoglu, S. (2003). Reliability and validity of personality disorder assessment using a systematic clinical interview: Evaluating an alternative to structured interviews. Journal of Personality Disorders, 17, 350Ð368. http://dx.doi.org/10.1521/pedi.17.4.351.23967 Westen, D., & Shedler, J. (1999a). Revising and assessing Axis II, Part I: Developing a clinically and empirically valid assessment method. The American Journal of Psychiatry, 156, 258Ð272. Westen, D., & Shedler, J. (1999b). Revising and assessing Axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. The American Journal of Psychiatry, 156, 273Ð285. Westen, D., Shedler, J., Durrett, C., Glass, S., & Martens, A. (2003). Personality diagnoses in adolescence: DSM–IV Axis II diagnoses and an empirically derived alternative. The American Journal of Psychiatry, 160, 952Ð966. http://dx.doi.org/10.1176/appi.ajp.160.5.952 Widiger, T. A. (2011). A shaky future for personality disorders. Personality Disorders: Theory, Research, and Treatment, 2, 54Ð67. http://dx.doi.org/10.1037/a0021855 Widlocher, D. (2007). Le Manuel Diagnostique Psychodynamique. Du nosographique au psycho- pathologique. Pour la Recherche. Bulletin de la Fédération Française de Psychiatrie, 52. Retrieved from www.psydoc-france.com Widlocher, D., & Thurin, J.-M. (2011). Le Manuel Diagnostique Psychodynamique: Integrer dans une perspective nosologique les apports d’une psychopathologie dynamique. Psychiatrie Fran- çaise, 42, 7Ð18. Wilson, T. D. (2009). Know thyself. Perspectives on Psychological Science, 4, 384Ð389. World Health Organization. (2004). International classification of diseases and health related problems, 10th edition. Geneva, Switzerland: Author. Zimmerman, M. (2012). Is there adequate empirical justification for radically revising the personality disorders section for DSM-5? Personality Disorders: Theory, Research, and Treatment, 3, 444Ð457. http://dx.doi.org/10.1037/a0022108 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.